GW1-2021-06392_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Raymond Brown 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
498 ft• 499 ft �
2313 it, ft
E
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
0 rc. 80 ft 6.1/4 ; 1° sdr21 pvc
Company Name
3457 161NNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) .18.GROUT_
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft bentonife pour
Monitoring E311ecovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVELPACK ifa livable
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. IL
Experimental Technology E3 Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additionatsheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock type.grain size,etc.
0 ft. 50 ft. soil
4.Date Well(s)Completed:2/24/2021 Well ED# ft. ft. soil/sandrock
Sa.Well Location: so ft. 685 ft blue granite
Sam Hooker ft. ft
Facility/Owner Name Facility ID# if a livable ft IL
1214 Mickey Rd. ft. fL
Physical Address,City,and Zip ft. ft -
Stokes .,.21.REMARKS _ ll l
County Pared Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.C tification-
N W 17 - C 4/29/2021
6.Is(are)the well(s)13Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 685 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:65 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Clenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 24 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016